Healthcare Provider Details

I. General information

NPI: 1013911833
Provider Name (Legal Business Name): JEFFREY JOHN STAPLES D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27001 LA PAZ RD STE 236
MISSION VIEJO CA
92691-5537
US

IV. Provider business mailing address

27001 LA PAZ RD STE 236
MISSION VIEJO CA
92691-5537
US

V. Phone/Fax

Practice location:
  • Phone: 949-768-0211
  • Fax: 949-768-7531
Mailing address:
  • Phone: 949-768-0211
  • Fax: 949-768-7531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number24610
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: